|Year : 2015 | Volume
| Issue : 1 | Page : 66-70
Novel surgical procedure for vestibular extension with platelet-rich fibrin
Anshul Singhal, D Deepa
Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India
|Date of Web Publication||7-Dec-2015|
Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Oral soft tissue augmentation procedures are performed routinely in an attempt to maintain gingival health. The standard procedures for increasing keratinized tissue and vestibular area are free gingival graft, vestibuloplasty, subepithelial connective tissue graft, rotated pedicle flaps. However, the supply is limited to treat the larger areas. This case report presents a technique utilizing platelet-rich fibrin to increase the depth of the vestibule and also the width of attached gingiva in the lower anterior teeth region.
Keywords: Platelet-rich fibrin, vestibular deepening, width of attached gingiva, wound healing
|How to cite this article:|
Singhal A, Deepa D. Novel surgical procedure for vestibular extension with platelet-rich fibrin. Int J Oral Health Sci 2015;5:66-70
| Introduction|| |
Periodontal plastic surgery is defined as a "surgical procedure performed to correct or eliminate anatomic, developmental, or traumatic deformities of gingiva or alveolar mucosa." The first detailed discussion of the rationale and techniques of the emerging field of mucogingival surgery was set forth in 1956 by Goldman et al. The vestibular extension operations for increasing the width of gingiva involves the production of a wound extending from gingival margin to a level some millimeters apical to mucogingival junction. The standard procedures for increasing keratinized tissue and vestibular area are free gingival graft, vestibuloplasty, subepithelial connective tissue graft, rotated pedicle flaps. The studies have shown that gingival and palatal grafts retain their tissue characteristics, after transplantation to an ectopic site.,, Because of these limitations and additional need of surgical site, dermal substitutes, growth factors, and other biomimetics are being considered as alternative or adjunctive treatment modalities. The goal of many of these technologies is to repair mucogingival tissue and to restore function and esthetics in a site-appropriate manner while reducing patient morbidity.
Platelet-rich fibrin (PRF) is a leukocyte and PRF biomaterial with a specific composition and three-dimensional architecture. PRF has a dense fibrin network with leukocytes, cytokines, structural glycoproteins, and also growth factors such as transforming growth factor β-1 (TGF-β), platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), and glycoproteins such as thrombospondin-1 are gradually released as the fibrin matrix is resorbed, aiding the process of healing. PRF enhances wound healing and regeneration, and several studies show rapid and accelerated wound healing with the use of PRF.,, It has been extensively used in hard and soft tissue augmentation but not tried for increasing the vestibular depth. In this case report, a surgical technique using PRF for vestibular extension in the mandibular anterior region has been described.
| Case Report|| |
A 19-year-old female patient reported to the Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, with a chief complaint of food lodgment in the lower anterior vestibule region and also difficulty in performing proper oral hygiene practices in the lower anterior teeth region. Medical history was noncontributory. Intraoral examination revealed inadequate vestibular depth in the lower anterior region, around 1 mm [Figure 1]. Scaling and root planing were performed, and the patient was motivated to undergo vestibular extension procedure using PRF for the increase in the depth of the vestibule. Informed consent duly signed by the patient was obtained before the procedure.
|Figure 1: (a) Pre-operative photograph after scaling and root planing, (b) Preoperative photograph showing inadequate vestibular depth in lower anterior region |
Click here to view
Preparation of platelet-rich fibrin
Before the surgical procedure, 10 ml of blood was drawn from the subject's antecubital site. The blood sample was collected in glass-coated plastic tubes without the addition of an anticoagulant. The blood containing tubes were immediately centrifuged for 10 min at 3000 revolutions per minute. The centrifuged blood mass presented with a structured fibrin clot in the middle of the tube between the red corpuscle layer at the bottom and the acellular plasma on the top. Fibrin clot could easily be retrieved from the tube and shaped freely and was used immediately after its collection. PRF was compressed between two tongue blades to take the form of a consistent membrane [Figure 2].
About 0.2% chlorhexidine digluconate rinse for intraoral and iodine solution for extraoral antisepsis were used. Following administration of 2% local anesthesia at the site of surgery, frenectomy was performed [Figure 3]. Incision was placed in the mid-vestibular region and extended deep into the labial sulcus from distal of lower right canine to the distal of lower left canine to create a suitable depth and width of vestibule [Figure 4]. After bleeding was controlled, PRF membrane was placed over the prepared recipient site [Figure 5] and stabilized with sutures (5–0) tied edge to edge on both sides [Figure 6]. Furthermore, sutures were placed at the base to ensure stability of the PRF membrane. Periodontal dressing was placed over the surgical site. Stability of the PRF was ensured by the sutures. Periodontal pack was given to provide comfort and also to protect the wound site. Antibiotics and analgesics (amoxicillin 500 mg 3 times per day and ibuprofen 400 mg 3 times per day for 5 days) were prescribed, along with chlorhexidine digluconate rinses (0.2%) twice daily for 2 weeks. The patient was instructed not to use a toothbrush or mechanical cleaning at the surgical area. Soft diet was advised for the 1st week of the healing period. After 14 days, the sutures and periodontal dressing were removed, and irrigation was done [Figure 7], and the patient was again recalled after 2 weeks. Uneventful healing by secondary intention was observed within 1 month, and 2 mm amount of gain in keratinized gingiva and vestibular depth of 3 mm were achieved [Figure 8], [Figure 9]a and [Figure 9]b.
|Figure 4: Vestibular incision extending from lower right canine to lower left canine |
Click here to view
|Figure 7: Postoperative photograph on the 14th day at the time of suture removal|
Click here to view
|Figure 8: Postoperative photographs showing uneventful healing at 1 month|
Click here to view
|Figure 9: (a) Postoperative photograph showing gain in keratinized tissue, (b) Postoperative photograph showing increased vestibular depth at 1 month|
Click here to view
| Discussion|| |
The adequate width of attached gingiva is required for the proper maintenance of oral hygiene. Any discrepancy in vestibular depth interferes in proper oral hygiene maintenance and may cause various mucogingival problems. However, the optimal goal for treating oral mucosal defects is to restore function while preserving esthetic appearance. At present, options are limited and rely predominantly on grafting techniques; due to the patient morbidity, as a result of graft harvesting and inability to restore the tissue that is esthetically similar to the native tissue has led to the search for alternative treatment options.
PRF is enriched with platelets, growth factors, and cytokines increasing the healing potential of both hard and soft tissue., The α-granules present in platelets contain growth factors such as PDGF, TGF-β, VEGF, and epidermal growth factor. PDGF has an important role in periodontal regeneration and wound healing and receptor for PDGF is present on gingiva, periodontal ligament, and cementum, and it activates fibroblasts and osteoblasts promoting protein synthesis PDGF also functions as a chemoattractant for fibroblasts and osteoblasts in gingiva and periodontal ligament resulting in their activation.,
PRF membrane has both mechanical adhesive properties and biologic functions such as fibrin glue; the presence of leukocytes and cytokines in the fibrin network can play a significant role in the self-regulation of inflammatory and infectious phenomena. Another advantage of this procedure is the avoidance of second surgical site for graft harvest, thus improving the patient compliance and reducing the postoperative morbidity. Vijayalakshmi et al. published a case report in which the fenestration defect around an implant was treated by the application of PRF, a second generation platelet concentrate along with bone graft and guided tissue regeneration membrane. In addition, another study using rhPDGF-BB and recombinant human fibroblast growth factor-2 (rhFGF-2) for intrabony defects showed a linear defect fill of 20.17% and 21.22% with PDGF and FGF-2, respectively.
| Conclusion|| |
PRF is easy to procure, not expensive and can be prepared in few minutes. Adequate depth of vestibule and width of attached gingiva was achieved using PRF as an adjunct for vestibular extension. However, further studies with longer study period are required to determine the success rate and the predictability of this procedure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Takei H, Azzi R, Han T. Periodontal plastic and esthetic surgery. In: Carranza FA, editor. Clinical Periodontology. 10th
ed. St. Louis: Elsevier; 2009. p. 1005-30.
Goldman HM, Schluger S, Fox L. Periodontal Therapy. St. Louis: CV Mosby Co.; 1956. p. 301-11.
Karring T, Ostergaard E, Löe H. Conservation of tissue specificity after heterotopic transplantation of gingiva and alveolar mucosa. J Periodontal Res 1971;6:282-93.
Karring T, Lang NP, Löe H. The role of gingival connective tissue in determining epithelial differentiation. J Periodontal Res 1975;10:1-11.
Wei PC, Laurell L, Lingen MW, Geivelis M. Acellular dermal matrix allografts to achieve increased attached gingiva. Part 2. A histological comparative study. J Periodontol 2002;73:257-65.
Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: From pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends Biotechnol 2009;27:158-67.
Dohan Ehrenfest DM, Diss A, Odin G, Doglioli P, Hippolyte MP, Charrier JB.In vitro
effects of Choukroun's PRF (platelet-rich fibrin) on human gingival fibroblasts, dermal prekeratinocytes, preadipocytes, and maxillofacial osteoblasts in primary cultures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:341-52.
Giannobile WV. Periodontal tissue engineering by growth factors. Bone 1996;19 1 Suppl: 23S-37S.
Su CY, Kuo YP, Tseng YH, Su CH, Burnouf T.In vitro
release of growth factors from platelet-rich fibrin (PRF): A proposal to optimize the clinical applications of PRF. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:56-61.
Giannobile WV, Hernandez RA, Finkelman RD, Ryan S, Kiritsy CP, D'Andrea M, et al.
Comparative effects of platelet-derived growth factor-BB and insulin-like growth factor-I, individually and in combination, on periodontal regeneration in Macaca fascicularis
. J Periodontal Res 1996;31:301-12.
Annunziata M, Oliva A, Buonaiuto C, Di Feo A, Di Pasquale R, Passaro I, et al. In vitro
cell-type specific biological response of human periodontally related cells to platelet-rich plasma. J Periodontal Res 2005;40:489-95.
Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM. The relevance of Choukroun's platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part I: A new grafting protocol. Implant Dent 2009;18:102-11.
Vijayalakshmi R, Rajmohan CS, Deepalakshmi D, Sivakami G. Use of platelet rich fibrin in a fenestration defect around an implant. J Indian Soc Periodontol 2012;16:108-12.
Khoshkam V, Chan HL, Lin GH, Mailoa J, Giannobile WV, Wang HL, et al
. Outcomes of regenerative treatment with rhPDGF-BB and rhFGF-2 for periodontal intra-bony defects: A systematic review and meta-analysis. J Clin Periodontol 2015;42:272-80.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]